Benjamin P. Levy, MD: Bevacizumab has been approved since the seminal work: the ECOG-4599 trial that looked at carboplatin/paclitaxel, which was the reference standard at that time, versus carboplatin/paclitaxel with the addition of bevacizumab, with bevacizumab included in the induction platinum doublet as well as in a continuation strategy. All of these patients had nonsquamous non–small cell lung cancer. They had, at the time of the enrollment of the trial, no evidence of brain metastases. This study, as I think we all know, demonstrated an improvement in response rate, progression-free survival, and overall survival with the addition of bevacizumab to carboplatin/paclitaxel. This drug has been approved since that time for patients with nonsquamous non–small cell lung cancer. Patients need to have at least treated brain metastases to be on this drug. There cannot be any uncontrolled brain metastases. They also shouldn’t have any evidence of any arterial thrombotic events. Venous thromboses is something that is allowed if it’s treated, and patients can even be on anticoagulation.

How do I use this drug in my day-to-day practice? I think we’re coming to a place in non–small cell lung cancer where treatment decisions have to be individualized, and bevacizumab is an integral role of that individualized treatment decision. Patients I’m thinking about, where I really need to elicit a response and I need to give a drug that I know is going to work and work quickly—patients that are perhaps younger and fitter—are patients who I would consider giving bevacizumab to with my platinum doublet. Patients who come through the door and aren’t bevacizumab eligible are patients who may have significant coronary artery disease or arterial thrombotic events, untreated brain metastases, or squamous cell histology. Those aren’t really the patients who I would give bevacizumab to. But that symptomatic patient whom I need to elicit a response quickly in and give a drug that I know works to, those are some of the considerations that I will use to deliver or not deliver this drug.

Ronald J. Scheff, MD: In my practice, I use bevacizumab in the first line when I’m using paclitaxel and carboplatin as my first-line platinum doublet. Based on the results from ECOG-4599, it’s very clear in my opinion that bevacizumab in combination with paclitaxel and carboplatin adds benefit. In my opinion, it’s less clear that bevacizumab adds benefit with other regimens. In my practice, the main role for bevacizumab in the frontline setting is in combination with paclitaxel and carboplatin.

Ann Tsao, MD: The field of metastatic non–small cell lung cancer is actually rapidly evolving. What has been standard practice before has included a platinum doublet, carboplatin/paclitaxel, and bevacizumab as both maintenance and as a standard regimen. In addition, some people have used platinum pemetrexed/bevacizumab followed by either bevacizumab or pembrolizumab maintenance or pembrolizumab/bevacizumab maintenance. We do know that these have been efficacious in our non–small cell lung cancer patients. The IMpower-150 study, which recently came out in a press release, has shown that carboplatin/paclitaxel/bevacizumab in addition to atezolizumab seems to have significant efficacy in our patients as well. So, I do anticipate that this field will rapidly evolve, and we may be considering a quadruplet regimen in some of our patients.

Transcript Edited for Clarity

Transcript:

Benjamin P. Levy, MD: Bevacizumab has been approved since the seminal work: the ECOG-4599 trial that looked at carboplatin/paclitaxel, which was the reference standard at that time, versus carboplatin/paclitaxel with the addition of bevacizumab, with bevacizumab included in the induction platinum doublet as well as in a continuation strategy. All of these patients had nonsquamous non–small cell lung cancer. They had, at the time of the enrollment of the trial, no evidence of brain metastases. This study, as I think we all know, demonstrated an improvement in response rate, progression-free survival, and overall survival with the addition of bevacizumab to carboplatin/paclitaxel. This drug has been approved since that time for patients with nonsquamous non–small cell lung cancer. Patients need to have at least treated brain metastases to be on this drug. There cannot be any uncontrolled brain metastases. They also shouldn’t have any evidence of any arterial thrombotic events. Venous thromboses is something that is allowed if it’s treated, and patients can even be on anticoagulation.

How do I use this drug in my day-to-day practice? I think we’re coming to a place in non–small cell lung cancer where treatment decisions have to be individualized, and bevacizumab is an integral role of that individualized treatment decision. Patients I’m thinking about, where I really need to elicit a response and I need to give a drug that I know is going to work and work quickly—patients that are perhaps younger and fitter—are patients who I would consider giving bevacizumab to with my platinum doublet. Patients who come through the door and aren’t bevacizumab eligible are patients who may have significant coronary artery disease or arterial thrombotic events, untreated brain metastases, or squamous cell histology. Those aren’t really the patients who I would give bevacizumab to. But that symptomatic patient whom I need to elicit a response quickly in and give a drug that I know works to, those are some of the considerations that I will use to deliver or not deliver this drug.

Ronald J. Scheff, MD: In my practice, I use bevacizumab in the first line when I’m using paclitaxel and carboplatin as my first-line platinum doublet. Based on the results from ECOG-4599, it’s very clear in my opinion that bevacizumab in combination with paclitaxel and carboplatin adds benefit. In my opinion, it’s less clear that bevacizumab adds benefit with other regimens. In my practice, the main role for bevacizumab in the frontline setting is in combination with paclitaxel and carboplatin.

Ann Tsao, MD: The field of metastatic non–small cell lung cancer is actually rapidly evolving. What has been standard practice before has included a platinum doublet, carboplatin/paclitaxel, and bevacizumab as both maintenance and as a standard regimen. In addition, some people have used platinum pemetrexed/bevacizumab followed by either bevacizumab or pembrolizumab maintenance or pembrolizumab/bevacizumab maintenance. We do know that these have been efficacious in our non–small cell lung cancer patients. The IMpower-150 study, which recently came out in a press release, has shown that carboplatin/paclitaxel/bevacizumab in addition to atezolizumab seems to have significant efficacy in our patients as well. So, I do anticipate that this field will rapidly evolve, and we may be considering a quadruplet regimen in some of our patients.